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Thakur M, Kuresan H, Dhanalakshmi S, Lai KW, Wu X. Soft Attention Based DenseNet Model for Parkinson’s Disease Classification Using SPECT Images. Front Aging Neurosci 2022; 14:908143. [PMID: 35912076 PMCID: PMC9326232 DOI: 10.3389/fnagi.2022.908143] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/05/2022] [Indexed: 11/25/2022] Open
Abstract
Objective Deep learning algorithms have long been involved in the diagnosis of severe neurological disorders that interfere with patients’ everyday tasks, such as Parkinson’s disease (PD). The most effective imaging modality for detecting the condition is DaTscan, a variety of single-photon emission computerized tomography (SPECT) imaging method. The goal is to create a convolutional neural network that can specifically identify the region of interest following feature extraction. Methods The study comprised a total of 1,390 DaTscan imaging groups with PD and normal classes. The architecture of DenseNet-121 is leveraged with a soft-attention block added before the final classification layer. For visually analyzing the region of interest (ROI) from the images after classification, Soft Attention Maps and feature map representation are used. Outcomes The model obtains an overall accuracy of 99.2% and AUC-ROC score 99%. A sensitivity of 99.2%, specificity of 99.4% and f1-score of 99.1% is achieved that surpasses all prior research findings. Soft-attention map and feature map representation aid in highlighting the ROI, with a specific attention on the putamen and caudate regions. Conclusion With the deep learning framework adopted, DaTscan images reveal the putamen and caudate areas of the brain, which aid in the distinguishing of normal and PD cohorts with high accuracy and sensitivity.
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Affiliation(s)
- Mahima Thakur
- Department of Electronics and Communication Engineering, SRM Institute of Science and Technology, Chennai, India
| | - Harisudha Kuresan
- Department of Electronics and Communication Engineering, SRM Institute of Science and Technology, Chennai, India
| | - Samiappan Dhanalakshmi
- Department of Electronics and Communication Engineering, SRM Institute of Science and Technology, Chennai, India
- *Correspondence: Samiappan Dhanalakshmi,
| | - Khin Wee Lai
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, Malaysia
- Khin Wee Lai,
| | - Xiang Wu
- School of Medical Information Engineering, Xuzhou Medical University, Xuzhou, China
- Xiang Wu,
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2
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Rogozinski S, Klietz M, Respondek G, Oertel WH, Grothe MJ, Pereira JB, Höglinger GU. Reduction in Volume of Nucleus Basalis of Meynert Is Specific to Parkinson’s Disease and Progressive Supranuclear Palsy but Not to Multiple System Atrophy. Front Aging Neurosci 2022; 14:851788. [PMID: 35431891 PMCID: PMC9012106 DOI: 10.3389/fnagi.2022.851788] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/24/2022] [Indexed: 12/29/2022] Open
Abstract
Objectives To study in vivo gray matter (GM) volumes of the nucleus basalis of Meynert (nbM) in different parkinsonian syndromes and assess their relationship with clinical variables. Methods T1-weighted magnetic resonance images from patients with progressive supranuclear palsy (PSP, N = 43), multiple system atrophy (MSA, N = 23), Parkinson’s disease (PD, N = 26), and healthy controls (HC, N = 29) were included. T1-weighted images were analyzed using a voxel-based morphometry approach implemented in the VBM8 toolbox, and nbM volumes were extracted from the spatially normalized GM images using a cyto-architectonically-defined nbM mask in stereotactic standard space. NbM volumes were compared between groups, while controlling for intracranial volume. Further, within each group correlation analyses between nbM volumes and the Mini Mental Status Examination (MMSE), Hoehn and Yahr stage, PSP Rating Scale, Unified Parkinson’s Disease Rating Scale part III and Frontal Assessment Battery scores were performed. Results Significantly lower nbM volumes in patients with PSP and PD compared to HC or patients with MSA were found. No significant correlations between MMSE and nbM volumes were detected in any of the subgroups. No significant correlations were found between clinical scores and nbM volumes in PSP or other groups. Conclusion nbM volumes were reduced both in PD and PSP but not in MSA. The lack of significant correlations between nbM and cognitive measures suggests that other factors, such as frontal atrophy, may play a more important role than subcortical cholinergic atrophy in PSP patients. These results may indicate that other drug-targets are needed to improve cognitive function in PSP patients.
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Affiliation(s)
- Sophia Rogozinski
- Department of Neurology, Hanover Medical School, Hanover, Germany
- *Correspondence: Sophia Rogozinski,
| | - Martin Klietz
- Department of Neurology, Hanover Medical School, Hanover, Germany
| | - Gesine Respondek
- Department of Neurology, Hanover Medical School, Hanover, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Wolfgang H. Oertel
- Department of Neurology, Philipps University of Marburg, Marburg, Germany
| | - Michel J. Grothe
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Seville, Spain
| | - Joana B. Pereira
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Günter U. Höglinger
- Department of Neurology, Hanover Medical School, Hanover, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
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3
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Beaurain M, Salabert AS, Ribeiro MJ, Arlicot N, Damier P, Le Jeune F, Demonet JF, Payoux P. Innovative Molecular Imaging for Clinical Research, Therapeutic Stratification, and Nosography in Neuroscience. Front Med (Lausanne) 2019; 6:268. [PMID: 31828073 PMCID: PMC6890558 DOI: 10.3389/fmed.2019.00268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 11/01/2019] [Indexed: 01/06/2023] Open
Abstract
Over the past few decades, several radiotracers have been developed for neuroimaging applications, especially in PET. Because of their low steric hindrance, PET radionuclides can be used to label molecules that are small enough to cross the blood brain barrier, without modifying their biological properties. As the use of 11C is limited by its short physical half-life (20 min), there has been an increasing focus on developing tracers labeled with 18F for clinical use. The first such tracers allowed cerebral blood flow and glucose metabolism to be measured, and the development of molecular imaging has since enabled to focus more closely on specific targets such as receptors, neurotransmitter transporters, and other proteins. Hence, PET and SPECT biomarkers have become indispensable for innovative clinical research. Currently, the treatment options for a number of pathologies, notably neurodegenerative diseases, remain only supportive and symptomatic. Treatments that slow down or reverse disease progression are therefore the subject of numerous studies, in which molecular imaging is proving to be a powerful tool. PET and SPECT biomarkers already make it possible to diagnose several neurological diseases in vivo and at preclinical stages, yielding topographic, and quantitative data about the target. As a result, they can be used for assessing patients' eligibility for new treatments, or for treatment follow-up. The aim of the present review was to map major innovative radiotracers used in neuroscience, and explain their contribution to clinical research. We categorized them according to their target: dopaminergic, cholinergic or serotoninergic systems, β-amyloid plaques, tau protein, neuroinflammation, glutamate or GABA receptors, or α-synuclein. Most neurological disorders, and indeed mental disorders, involve the dysfunction of one or more of these targets. Combinations of molecular imaging biomarkers can afford us a better understanding of the mechanisms underlying disease development over time, and contribute to early detection/screening, diagnosis, therapy delivery/monitoring, and treatment follow-up in both research and clinical settings.
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Affiliation(s)
- Marie Beaurain
- CHU de Toulouse, Toulouse, France.,ToNIC, Toulouse NeuroImaging Center, Inserm U1214, Toulouse, France
| | - Anne-Sophie Salabert
- CHU de Toulouse, Toulouse, France.,ToNIC, Toulouse NeuroImaging Center, Inserm U1214, Toulouse, France
| | - Maria Joao Ribeiro
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France.,Inserm CIC 1415, University Hospital, Tours, France.,CHRU Tours, Tours, France
| | - Nicolas Arlicot
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France.,Inserm CIC 1415, University Hospital, Tours, France.,CHRU Tours, Tours, France
| | - Philippe Damier
- Inserm U913, Neurology Department, University Hospital, Nantes, France
| | | | - Jean-François Demonet
- Leenards Memory Centre, Department of Clinical Neuroscience, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Pierre Payoux
- CHU de Toulouse, Toulouse, France.,ToNIC, Toulouse NeuroImaging Center, Inserm U1214, Toulouse, France
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4
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Fabbrini G, Fabbrini A, Suppa A. Progressive supranuclear palsy, multiple system atrophy and corticobasal degeneration. ACTA ACUST UNITED AC 2019; 165:155-177. [DOI: 10.1016/b978-0-444-64012-3.00009-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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5
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Murley AG, Rowe JB. Neurotransmitter deficits from frontotemporal lobar degeneration. Brain 2018; 141:1263-1285. [PMID: 29373632 PMCID: PMC5917782 DOI: 10.1093/brain/awx327] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/05/2017] [Accepted: 10/03/2017] [Indexed: 12/11/2022] Open
Abstract
Frontotemporal lobar degeneration causes a spectrum of complex degenerative disorders including frontotemporal dementia, progressive supranuclear palsy and corticobasal syndrome, each of which is associated with changes in the principal neurotransmitter systems. We review the evidence for these neurochemical changes and propose that they contribute to symptomatology of frontotemporal lobar degeneration, over and above neuronal loss and atrophy. Despite the development of disease-modifying therapies, aiming to slow neuropathological progression, it remains important to advance symptomatic treatments to reduce the disease burden and improve patients' and carers' quality of life. We propose that targeting the selective deficiencies in neurotransmitter systems, including dopamine, noradrenaline, serotonin, acetylcholine, glutamate and gamma-aminobutyric acid is an important strategy towards this goal. We summarize the current evidence-base for pharmacological treatments and suggest strategies to improve the development of new, effective pharmacological treatments.
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Affiliation(s)
- Alexander G Murley
- Department of Clinical Neurosciences, University of Cambridge, Herchel Smith Building, Robinson Way, Cambridge, CB2 0SZ, UK
| | - James B Rowe
- Department of Clinical Neurosciences, University of Cambridge, Herchel Smith Building, Robinson Way, Cambridge, CB2 0SZ, UK
- MRC Cognition and Brain Sciences Unit, University of Cambridge, 15 Chaucer Road, Cambridge, CB2 7EF, UK
- Behavioural and Clinical Neurosciences Institute, University of Cambridge, Sir William Hardy Building, Downing Street, Cambridge, CB2 3EB, UK
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6
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Jagadeesan AJ, Murugesan R, Vimala Devi S, Meera M, Madhumala G, Vishwanathan Padmaja M, Ramesh A, Banerjee A, Sushmitha S, Khokhlov AN, Marotta F, Pathak S. Current trends in etiology, prognosis and therapeutic aspects of Parkinson's disease: a review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:249-262. [PMID: 29083328 PMCID: PMC6142835 DOI: 10.23750/abm.v88i3.6063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/01/2017] [Accepted: 02/06/2017] [Indexed: 02/07/2023]
Abstract
Parkinson's disease (PD) is a movement disorder, mainly affecting population consisting of the aged. PD occurs chiefly due to progressive loss of dopaminergic neurons in nigrostriatal pathway. Largely, PD patients suffer from non-motor symptoms, such as depression, anxiety, fatigue, and sleep disorders, that needs further investigation and addressing during PD research. Depression in PD is a predominant and complex symptom, and its pathology exists extrinsic to the nigrostriatal system. This disease can ultimately be managed by a combination of regular physiotherapy and proper medication. Taking together the present scenario of PD, including the nature of disease, characteristics, treatment, diagnosis of the patients with PD, these outcomes were reviewed to be explored along with many speech-based solutions to PD in this study. This neurodegenerative disorder needs advancement in research and development which can help patients with PD to lead a normal life.
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7
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Chiu WZ, Donker Kaat L, Boon AJW, Kamphorst W, Schleicher A, Zilles K, van Swieten JC, Palomero-Gallagher N. Multireceptor fingerprints in progressive supranuclear palsy. ALZHEIMERS RESEARCH & THERAPY 2017; 9:28. [PMID: 28412965 PMCID: PMC5393015 DOI: 10.1186/s13195-017-0259-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/24/2017] [Indexed: 05/29/2023]
Abstract
Background Progressive supranuclear palsy (PSP) with a frontal presentation, characterized by cognitive deficits and behavioral changes, has been recognized as an early clinical picture, distinct from the classical so-called Richardson and parkinsonism presentations. The midcingulate cortex is associated with executive and attention tasks and has consistently been found to be impaired in imaging studies of patients with PSP. The aim of the present study was to determine alterations in neurotransmission underlying the pathophysiology of PSP, as well as their significance for clinically identifiable PSP subgroups. Methods In vitro receptor autoradiography was used to quantify densities of 20 different receptors in the caudate nucleus and midcingulate area 24' of patients with PSP (n = 16) and age- and sex-matched control subjects (n = 14). Results Densities of γ-aminobutyric acid type B, peripheral benzodiazepine, serotonin receptor type 2, and N-methyl-d-aspartate receptors were significantly higher in area 24′ of patients with PSP, where tau impairment was stronger than in the caudate nucleus. Kainate and nicotinic cholinergic receptor densities were significantly lower, and adenosine receptor type 1 (A1) receptors significantly higher, in the caudate nucleus of patients with PSP. Receptor fingerprints also segregated PSP subgroups when clinical parameters such as occurrence of frontal presentation and tau pathology severity were taken into consideration. Conclusions We demonstrate, for the first time to our knowledge, that kainate and A1 receptors are altered in PSP and that clinically identifiable PSP subgroups differ at the neurochemical level. Numerous receptors were altered in the midcingulate cortex, further suggesting that it may prove to be a key region in PSP. Finally, we add to the evidence that nondopaminergic systems play a role in the pathophysiology of PSP, thus highlighting potential novel treatment strategies.
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Affiliation(s)
- Wang Zheng Chiu
- Department of Neurology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Laura Donker Kaat
- Department of Neurology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Agnita J W Boon
- Department of Neurology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Wouter Kamphorst
- Department of Neuropathology, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands
| | - Axel Schleicher
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Jülich, Germany
| | - Karl Zilles
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Jülich, Germany.,Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany.,Jülich Aachen Research Alliance (JARA), Translational Brain Medicine, Aachen, Germany
| | - John C van Swieten
- Department of Neurology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Nicola Palomero-Gallagher
- Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Jülich, Germany. .,Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany.
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8
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Looi JCL, Macfarlane MD, Walterfang M, Styner M, Velakoulis D, Lätt J, van Westen D, Nilsson C. Morphometric analysis of subcortical structures in progressive supranuclear palsy: In vivo evidence of neostriatal and mesencephalic atrophy. Psychiatry Res 2011; 194:163-75. [PMID: 21899988 PMCID: PMC3204393 DOI: 10.1016/j.pscychresns.2011.07.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 06/25/2011] [Accepted: 07/02/2011] [Indexed: 01/17/2023]
Abstract
Progressive supranuclear palsy (PSP) is a neurodegenerative disease characterized by gait and postural disturbance, gaze palsy, apathy, decreased verbal fluency and dysexecutive symptoms, with some of these clinical features potentially having origins in degeneration of frontostriatal circuits and the mesencephalon. This hypothesis was investigated by manual segmentation of the caudate and putamen on MRI scans, using previously published protocols, in 15 subjects with PSP and 15 healthy age-matched controls. Midbrain atrophy was assessed by measurement of mid-sagittal area of the midbrain and pons. Shape analysis of the caudate and putamen was performed using spherical harmonics (SPHARM-PDM, University of North Carolina). The sagittal pons area/midbrain area ratio (P/M ratio) was significantly higher in the PSP group, consistent with previous findings. Significantly smaller striatal volumes were found in the PSP group - putamina were 10% smaller and caudate volumes were 17% smaller than in controls after controlling for age and intracranial volume. Shape analysis revealed significant shape deflation in PSP in the striatum, compared to controls; with regionally significant change relevant to frontostriatal and corticostriatal circuits in the caudate. Thus, in a clinically diagnosed and biomarker-confirmed cohort with early PSP, we demonstrate that neostriatal volume and shape are significantly reduced in vivo. The findings suggest a neostriatal and mesencephalic structural basis for the clinical features of PSP leading to frontostriatal and mesocortical-striatal circuit disruption.
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Affiliation(s)
- Jeffrey Chee Leong Looi
- Research Centre for the Neurosciences of Ageing, Academic Unit of Psychological Medicine, School of Clinical Medicine, Australian National University Medical School, Canberra, Australia, Correspondence: Associate Professor Jeffrey Looi, Academic Unit of Psychological Medicine, ANU Medical School, Building 4, Level 2, Canberra Hospital, Garran A.C.T. 2605,
| | - Matthew D. Macfarlane
- Research Centre for the Neurosciences of Ageing, Academic Unit of Psychological Medicine, School of Clinical Medicine, Australian National University Medical School, Canberra, Australia
| | - Mark Walterfang
- Melbourne Neuropsychiatry Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Martin Styner
- Department of Psychiatry and Department of Computer Science, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Dennis Velakoulis
- Melbourne Neuropsychiatry Centre, Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Jimmy Lätt
- Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Danielle van Westen
- Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden,Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Christer Nilsson
- Geriatric Psychiatry, Department of Clinical Sciences, Lund University, Lund, Sweden
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9
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Preliminary studies of differential impairments of the dopaminergic system in subtypes of progressive supranuclear palsy. Nucl Med Commun 2010; 31:974-80. [DOI: 10.1097/mnm.0b013e32833e5f90] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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10
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O'Sullivan SS, Djamshidian A, Ahmed Z, Evans AH, Lawrence AD, Holton JL, Revesz T, Lees AJ. Impulsive-compulsive spectrum behaviors in pathologically confirmed progressive supranuclear palsy. Mov Disord 2010; 25:638-42. [DOI: 10.1002/mds.22902] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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11
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Warren NM, Piggott MA, Lees AJ, Perry EK, Burn DJ. Intact coupling of M1 receptors and preserved M2 and M4 receptors in the cortex in progressive supranuclear palsy: Contrast with other dementias. J Chem Neuroanat 2008; 35:268-74. [DOI: 10.1016/j.jchemneu.2008.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Revised: 01/08/2008] [Accepted: 01/08/2008] [Indexed: 12/16/2022]
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12
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Warren NM, Piggott MA, Lees AJ, Burn DJ. The basal ganglia cholinergic neurochemistry of progressive supranuclear palsy and other neurodegenerative diseases. J Neurol Neurosurg Psychiatry 2007; 78:571-5. [PMID: 17178818 PMCID: PMC2077948 DOI: 10.1136/jnnp.2006.099937] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Progressive supranuclear palsy (PSP) is a progressive neurodegenerative disorder involving motor and cognitive dysfunction. Currently, there is no effective treatment either for symptomatic relief or disease modification. This relates, in part, to a lack of knowledge of the underlying neurochemical abnormalities, including cholinergic receptor status in the basal ganglia. AIM To measure muscarinic M2 and M4 receptors in the basal ganglia in PSP. METHODS The muscarinic M2 (presynaptic) and M4 (postsynaptic) receptors in the striatum, pallidum and adjacent insular cortex were autoradiographically measured in pathologically confirmed cases of PSP (n = 18), and compared with cases of Lewy body dementias (LBDs; n = 45), Alzheimer's disease (AD; n = 39) and controls (n = 50). RESULTS In cases of PSP, there was a reduction in M2 and M4 receptors in the posterior caudate and putamen compared to controls, but no significant changes in the pallidum. Cases with AD showed lower M2 receptors in the posterior striatum. Groups with LBD and AD showed higher M2 binding in the insular cortex compared with controls. CONCLUSIONS The results suggest loss of posterior striatal cholinergic interneurones in PSP, and reduction in medium spiny projection neurones bearing M4 receptors. These results should be taken in the context of more widespread pathology in PSP, but may have implications for future trials of cholinergic treatments.
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Affiliation(s)
- N M Warren
- Institute for Ageing and Health, Newcastle University, New Castle upon Tyne, UK.
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